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Home My WebLink AboutJack Conway Realtor 7/10/2018Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: STREET FAIR -FAMILY FUN NIGHT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:, Whose place of business is: JACK CONWAY REALTOR - FAMILY FUN NIGHT NORTH MAIN STREET PERSON(S) IN CHARGE: SHERRELL PREFONTAINE, MANAGER Permit Expires: JUIY 10, 2018 Food Fee: License Number: FFN-9 n; T BOARD OF HEALTH .MichaeCMcCCean, Chairman 0 1`�' FOR BOARD OF HEALTH USE ONLY I - -J.5 Date Received Date Inspected Approved By Permit # Issued Mansfield Family Fun Night Food Establishment Permit Application Establishment Name: g K CJ x Establishment Address: /' -Cv- r Establishment Mailing Address (tiff different): Establishment Telephone No: Applicant Name & Title: Applicant Mailing Address; "�q�Q� _-�; �L- Applicant Phone Number: Applicant Email y Establishment Owned By; An association Water Source: Town A corporation An individual Sewage disposal: Town A partnership Other legal entity Days and Hours of Operation: 4PM to Midnight Location: Street Fair Establishment Type Snack Food Operations: PHF- potentially hazardous food(time/temperature controls required) (check all that apply) Definitions: Non-PHFs - non- potentially hazardous food (no time/temperature controls required) RTE- ready -to -eat foods Ex. sandwiches, salads, muffins which need no furtherprocessing) ❑ Distribution of Commercially Pre -Packaged candy or bottled drinks A Preparation and distribution of popcorn, cotton candy, open hot and cold drinks. ❑ Distribution of foods that are cut up and served. Other (Describe): W O,)L-"A� S"1'6-C. c""-e S. To be completed by the Board of Health Total Permit Fee: FEE WAIVED I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on hoW-to obtain copies of 105 CMR,590,000,and the federal Food Code. Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. 7 �? Signature of Individual or Corporate Name: C� 6. U 12 TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of IndividA1 or Corporate Name 1)V — t71-�9/1 *"Social Security No. (Voluntary) or Federal fdenlificalim Number r By; Corporate Officer Waiid glory, if Applicable) .*This license Will not be issued -unless this certification clause is signed by the applicant. "' Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. The Commoit.ivetalth ofMmuachusetts Department of Industrial Aceirlents i% . f I ce of lit vestigatioit s 600 Washington Street uIV Boston, MA 02111 tnwwamiss,govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Naine: tJ(2c 3* i w as � b 4t_ 7"rlc- Phone #: Arc y i in employer? Check file lip )ropriate box: Business Type (required): 1. ' I am a employer with —� f _ employees (full and/ 5• ❑ Retriii 2. ❑ or part-time),* 1 G. ❑ 1ZystnuranVl3ar/Bating Esfablishincnt ran a sole proprietor or partnership and have no 7• 2 Office and/or Shies (inch real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] S. ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have to.[] Manufacturing 4. ❑ no employees. [No workers' comp, insurance required)* We i LEI I,leaith i.al'C are a non-profit organization, staffed by volunteers, with no employees. [No workers' conga. insurance req.) 12.❑ Other "Any upplicent that checks box ill must also lilt out the section below shoving Ibeh workers' compeosatioa policy information. _. °'ll'the coryorate a(rcers have exempted themselves, but the colporatioil has other employees, it workei:v' componsulion policy is required and such all orgauizalion should check box IN 1 oar no employer that isproviding worliers' compensation insurance for my employees. Be/on, is thepo/icy Lrforin(ttioll. Insurance CompaayNotre: l fI-0— r/�vvf/6h1rL /rf/jlJ/j (ZQ insurer's City/Statc/Zip: Policy fi or Self -ins, Lie. ik % lJ � /�a `l m o p "5_^ Expiri tion Date: 01 l o r / ) t 4 Attach it copy of the workers' cotrgiensatimt policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of iVIGL, c. 152 can lend to litc imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violotor, Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DiA for insurance coverage verification. 1 do hereby cer17, tinder c ppftPN and penalties ofpeijtny that the itrjormation provided above is true and correct. Ofllchil use only. Do not write hi this area, to be completed by clip or town official. City 01' Town; Permit/License P Issuing Authority (circle our): 1. Board of Ileaith 2. Building Deportment 3. City/Town Clerk 4. Licensing Board 5, Selectmen's Office 4. Outer Contact Phone www.nutss.gov/Ain Hanover Insurance Group.. WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 02 WORKERS COMPENSATION RENEWAL INFORMATION PAGE RENEWAL OF WDN-9417783-05 QARRIFR r.gnF Nfl 11A11 Policy Number Po icy Period From To Coverage is Prov tled in the- - - Agency Code WHN-9417783-06 1 01/01/2018 01101/2019" THE HANOVER INSURANCE COMPANY 3202246 I CM I. Namea Insurea anti Aaaress JACK CONWAY & CO INC 137 WASHINGTON ST NORWELL, MA 02061 Federal ID No. 042313916 SEE ATTACHED SCHEDULE OF WORKPLACES NOT SHOWN ABOVE, IF APPLICABLE SEE CONTINUATION OF NAMED ENTITY OF INSURED - CORPORATION Agent Telephone: 781-749-4310 WALTER J. MAY INSURANCE AGENCY, INC. 188 WHITING STREET HINGHAM, MA 02043 Bureau File No, 000004372 ADDITIONAL LOCATIONS FOR OTHER INSURED SCHEDULE. ITEM 2. POLICY PERIOD- 01/01/18 TO 01/01/19 12:01 AM STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN. -------------------------- -------------------------------------------------------- ITEM 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAW AND ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE FOLLOWING STATES - MA. ----------------------------------------------------.___-------_-__-- B. PART TWO OF `PHIS POLICY APPLIES TO EMPLOYERS' LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED IN ITEM 3A: BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT --------------------------------------------------..-___-_---------__ C. PART THREE OF' THIS POLICY APPLIES TO OTHER STATES INSURANCE FOR THE FOL- LOWING STATES- ALL STATES EXCEPT ND,OH,WA,WY, AND THOSE, STATES SPECIFICALLY NAMED IN ITEM 3A. ------------------------------------------------------------- ------.. D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS AND SCHEDULES FORMING PART OF THIS POLICY. ---------------------------------------------------------------------------------- ITEM 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS, ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. ------------------;-_---__------;---____--..--_----___ -___---EST_---- CLASSIFICATION OF OPERATIONS ANNUAL PREMIUM SEE ATTACHED SCHEDULE OF OPERATIONS PREMIUM DISCOUNT MINIMUM PREMIUM $500 EXPENSE CONSTANT PREMIUM FOR TERRORISM TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM ALL OTHER STATE TAXES AND ASSESSMENTS TOTAL STATE TAXES AND ASSESSMENTS TOTAL EST ANNUAL PREMIUM INCLUDING ALL TAXES AND ASSESSMENTS COUNTERSIGNED THIS DAY OF - - - - - - - - - - - - - - - AUTHORIZED REPRESENTATIVE BRANCH OFFICE:100 NORTH PARKWAY WORCESTER MA 01605 IF THE BILL FOR YOUR POLICY IS NOT ENCLOSED, IT WILL BE SENT TO YOU SEPARATELY. Form 331-0226 (9-03) WC00000113 Date Issued: 01 03/2018 ORIGINAL/INSURED Payment Type: DIRECT BILL GROUP NAME: REAL ESTATE - TARGET GROUP NUMBER: ZBS MOLCI Mansfield Board of Health Waiver 2017 for Food Permit Date 3 t *Put the name of your restaurant on first line then sign the form. We, OLCOC request a waiver of the Food Service Permit Fee for the following reason: Family Fun Night 2017 Thank you, -_ ignature J Title